ࡱ> PdMNOc ~ bjbj ff1-H H 84T%Lc%c%c%W/%0\00GSISISISISISIS$WBZmSs2/@W/s2s2mSc%c% T666s2Fc%c%GS6s2GS66JoLc%2F#K3ST0T9K60\20\,oLoL0\L0Z 1@6K141000mSmS4H000Ts2s2s2s20\000000000H S: HEALTHCARE PROFESSIONALS ADDITIONAL INFORMATION REQUEST Answer each question on behalf of all entities seeking insurance coverage, unless specifically requested otherwise. *NOTE coverage is not offered for Medical Doctors (including Dentists), Advanced Practice Registered Nurses (including Nurse Practitioners, Clinical Nurse Specialists or any other type of nurse that prescribes medications, or provides diagnoses or treatment) or Physicians Assistants. An Additional Information section is provided at the end of this document for any information that exceeds the space provided. GENERAL INFORMATION Proposed First Named Insured & Other Named Insured(s):  FORMTEXT      Today's Date:  FORMTEXT      Proposed Effective Date (mm/dd/yyyy):  FORMTEXT      Proposed Expiration Date (mm/dd/yyyy):  FORMTEXT        CORONER/EMT/NURSES/SOCIAL SERVICES WORK INFORMATION POSITION HELD FULL-TIMEPART-TIMEVOLUNTEERSEmployee CountEmployee CountTotal Hours**Volunteer CountTotal Hours**Coroner (Other than Medical Doctors) FORMTEXT       FORMTEXT       FORMTEXT      EMT Only FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Firefighter w/EMT Certification FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Firefighters including First Response not EMT Certified FORMTEXT       FORMTEXT       FORMTEXT      Jail Nurses FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Nurses (Other than Advanced Practice Registered Nurses*) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Social Workers/Case Workers/Foster Care Workers/ Counselors/Therapists FORMTEXT       FORMTEXT       FORMTEXT      Other FORMTEXT       FORMTEXT       FORMTEXT      * An advanced practice registered nurse is a nurse practitioner, clinical nurse specialist, or any other type of nurse who prescribes medications, or provides diagnoses or treatment ** Total Hours equals the number of hours worked for all Part-Time and/or Volunteer workers in an average week 1. Describe any licenses held:  FORMTEXT         Do you verify license or certification status?........................................................................................ FORMCHECKBOX  Yes  FORMCHECKBOX  No Do you check for any pending license suspensions or revocations or any pending disciplinary action?.................................................................................................................................................. FORMCHECKBOX  Yes  FORMCHECKBOX  No Do you conduct local and federal background checks?......................................................................  FORMCHECKBOX  Yes  FORMCHECKBOX  No Do all departments have an established policies and procedures manual?........................................ FORMCHECKBOX  Yes  FORMCHECKBOX  No If No is selected for any of the above, please provide details:  FORMTEXT        2. If you have a coroner and coverage is requested, does the coroner conduct autopsies? & & & & & & &  FORMCHECKBOX  Yes  FORMCHECKBOX  No 3. Has the insured or organization been involved in any claims, suits, or incidents arising out of counseling services?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 4. Has insurance been canceled, declined or non-renewed for any reason during the last 3 years or is cancellation or non-renewal pending? (Not Applicable in Missouri)  FORMCHECKBOX  Yes  FORMCHECKBOX  No  INSURANCE REQUIREMENTS INFORMATION 5. Do you require the contracted health care service providers or professionals providing services to your organization to carry their own professional liability insurance?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 6. Are certificates of insurance obtained?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 7. Are you named as an additional insured under the contracted professionals policy?  FORMCHECKBOX  Yes  FORMCHECKBOX  No EMT / FIRE DEPARTMENT / PARAMEDIC INFORMATION 8. Are mutual aid agreements in place with neighboring communities?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 9. Is Entity responsible for transporting injured persons?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 10. Are all volunteers fully trained and certified according to minimum state requirements?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 11. Is a substance abuse testing program in place, including volunteers?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 12. Are EMTs / Paramedics in contact with the hospital/doctors at all times when responding to a call?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 13. Are response times monitored and problems investigated?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 14. Are written records kept of all calls, with a description of treatment and patient delivery to the hospital for medical response?  FORMCHECKBOX  Yes  FORMCHECKBOX  No How long are the records kept? FORMTEXT        NURSE/JAIL NURSE ADDITIONAL INFORMATION 15. Describe services provided:  FORMTEXT       16. Do you have any advanced practice registered nurses* (e.g., nurse practitioners, clinical nurse specialists)?............................................  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, describe services:  FORMTEXT        SOCIAL SERVICES INFORMATION 17. Indicate whether you provide the following services check all that apply:  FORMCHECKBOX  Adoption  FORMCHECKBOX  Alternative incarceration home  FORMCHECKBOX  Foster care placement  FORMCHECKBOX  General psychological counseling  FORMCHECKBOX  Home care, home nursing, or similar type operation  FORMCHECKBOX  Marriage and family counseling  FORMCHECKBOX  Pastoral counseling  FORMCHECKBOX  Specialized counseling services (drug abuse, depression, stress management, etc.) describe:  FORMTEXT        FORMCHECKBOX  Substance abuse detoxification services  FORMCHECKBOX  Suicide or crisis hotline  FORMCHECKBOX  Vocation rehabilitation  FORMCHECKBOX  Other, describe:  FORMTEXT       FRAUD STATEMENTS  ATTENTION APPLICANTS IN THE FOLLOWING JURISDICTIONS ALABAMA, ARKANSAS, DISTRICT OF COLUMBIA, MARYLAND, NEW MEXICO, AND RHODE ISLAND: Any person who knowingly (or willfully in MD) presents a false or fraudulent claim for payment of a loss or benefit or who knowingly (or willfully in MD) presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. FLORIDA: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. KANSAS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for the insurance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act. 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(In New York, the civil penalty is not to exceed five thousand dollars ($5,000) and the stated value of the claim for each such violation.) LOUISIANA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. MAINE, TENNESSEE, VIRGINIA, AND WASHINGTON: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. NEW JERSEY: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. OKLAHOMA: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. OREGON: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison. SIGNATURES Producer information only required in Florida and Iowa. 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FORMCHECKBOX  Electronic Signature and Acceptance Authorized Representative  FORMCHECKBOX  Electronic Signature and Acceptance Producer ADDITIONAL INFORMATION AGHaCDEFGHIJKLMNOYZ[пппޮzk^L#hbh60J5@CJ^JaJh60J5CJ^JaJhIh60J@CJ^Jh2h60J@^JaJ&hm*hRCJOJQJ\]^JaJ hRCJOJQJ\]^JaJ h6CJOJQJ\]^JaJ hbh6CJOJQJ^JaJh6CJOJQJ^JaJ#hbh65CJOJQJ^JaJh65CJOJQJ^JaJIJKLMNOZ[b $If]gd4 $Ifgd4 5$s(($d%d&d'dNOPQ]^sa$gd6gd6 LN^`bdxоb?????𾕀Ejh6_h60J@B* CJOJQJU^JaJmHnHphu;jO7h6_h65B* CJOJQJU^JaJph)h6_h60J@B* CJ^JaJph2jh6_h60J@B* CJU^JaJphh6_h60J@CJ^J#h6_h60J5@CJ^JaJh6CJOJQJ^JaJ#hbh60J5@CJ^JaJh60J5@CJ^JaJxz|~Ǥǒ~iKǤǒ;j#8h6_h65B* CJOJQJU^JaJph)h6_h60J@B* CJ^JaJph&h6_h60J56@CJ^JaJ#h6_h60J5@CJ^JaJEjh6_h60J@B* CJOJQJU^JaJmHnHphu2jh6_h60J@B* CJU^JaJph;j7h6_h65B* CJOJQJU^JaJph.`WWJWWW $If]gd4 $Ifgd4 kd8$$IflF *X t06    44 lapyt4  "$&(*,.¤ׁooQׁoo;j9h6_h65B* CJOJQJU^JaJph#h6_h60J5@CJ^JaJEjh6_h60J@B* CJOJQJU^JaJmHnHphu;jO9h6_h65B* CJOJQJU^JaJph)h6_h60J@B* CJ^JaJph2jh6_h60J@B* CJU^JaJphh6_h60J@CJ^J$&(*,.0246VXjjjjjLjjjjj;jO;h6_h65B* CJOJQJU^JaJphEjh6_h60J@B* CJOJQJU^JaJmHnHphu;j#:h6_h65B* CJOJQJU^JaJph)h6_h60J@B* CJ^JaJph2jh6_h60J@B* CJU^JaJph#h6_h60J5@CJ^JaJ&h6_h60J56@CJ^JaJ6V~`WWWWWW $Ifgd4 kd:$$IflF *X t06    44 lapyt4 Xlnprtvxz|~+̲}}_}}HHHH,hbh60J5@B*CJ^JaJph;j#<h6_h65B* CJOJQJU^JaJph#h6_h60J5@CJ^JaJEjh6_h60J@B* CJOJQJU^JaJmHnHphu2jh6_h60J@B* CJU^JaJph;j;h6_h65B* CJOJQJU^JaJph)h6_h60J@B* CJ^JaJph,-`[S[[[[$a$gd6gd6kd<$$IflF *X t06    44 lapyt4 +,-.<=>պ՝պՀsdXI:s8UhIh60J@CJ^Jh2h60J@^JaJh60J@CJ^Jhdh60J@^JaJh60J5CJ^JaJ8j=h&h6B*CJOJQJU^JaJph8j?=h&h6B*CJOJQJU^JaJph5jhbh60J5@B*CJU^JaJph,hbh60J5@B*CJ^JaJph&h60J5@B*CJ^JaJph      $a$gd4gd( !d(xgdMp$a$gd6<gd6gd65$s(($d%d&d'dNOPQ]^sa$gd6This area may be used to provide additional information to any question. 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